This proposal is the third submission of application number R01 AA013806-01 which was originally submitted in response to Request for Application Number AA02.002 ("Research on Alcohol Health Disparities") and most recently reviewed February 13, 2003 by the National Institute on Alcohol Abuse and Alcoholism Health Services Research Review sub-committee (AA-2). The application has again been extensively revised in response to reviewer comments. Nonetheless, this health services research study continues to be motivated by health disparities such as the high rates of morbidity and mortality related to alcohol use among American Indians. Given these health disparities, it is worrisome that there have been few studies examining relationships between treatments and outcomes for natives with alcohol problems. In particular, there is little or no research on services for urban Native Americans with alcohol abuse or dependence. This lack of information is unfortunate since most American Indians now live in cities. The proposed project will examine processes of treatment and outcomes among clients of programs focusing on American Indians in Seattle, Washington and Portland, Oregon. The Seattle Indian Health Board and the Native American Rehabilitation Association in Portland, Oregon primarily serve urban American Indians, are closely connected with general medical services, offer ancillary care such as family therapy, provide numerous treatment modalities for individuals with alcohol problems, and support ongoing research projects. Both agencies serve members of several tribes and both have clients who spend part of the year in the city and part on reservations. Both agencies have adapted for Native people and incorporated into their treatment programs standardized therapies including Motivational Enhancement and Cognitive-Behavioral Treatment. The project will use an inception cohort design. Clients presenting for treatment of alcohol problems at the study programs will be informed about the project. After informed consent is obtained, subjects will be interviewed using instruments such as the Addiction Severity Index and the Project Match Form 90. Subjects will be interviewed again six months, 12, and 18 months after baseline. Outcomes of interest will include abstinence, number of drinking days, alcohol-related problems, psychiatric problems, general medical problems, and satisfaction with services. Interviews with clients and providers, observations of treatment sessions, and reviews of taped treatment encounters will be employed to elicit details of treatment services received. Hierarchical linear models and structural equations models will be used to relate treatments to outcomes. Predictors will include variables describing culturally specific treatments provided to the Native clients as well as measures of clinician cultural competence. Administrative data will be used to compare outcomes for American Indians versus general population clients. Information generated from the project will be useful in devising optimal treatment for indigenous people living in urban areas and in planning randomized clinical trials. The research team (headed by a Cherokee psychiatrist and including members of several tribes) will disseminate results in collaboration with the newly funded American Indian and Alaska Native National Resource Center on Substance Abuse Prevention and Treatment.